A poster shows how to use a syringe safely inside a safe injection site for drug addicts in Vancouver’s Downtown Eastside neighborhood.
Photograph: Andy Clark/Reuters

Whenever Dean Wilson walks people through Vancouver’s Downtown Eastside neighbourhood, he leads them past an unassuming glass door on Hastings Street before stopping at a community garden.

It’s here that he’ll casually mention that they just passed North America’s first supervised injection clinic.

“People go, ‘What? Where?’” Wilson said. “And that’s what we wanted. We don’t want some blinking sign saying ‘junkies line up here’. It’s just another medical office door you can walk in – and you can get well there.”

Wilson, 61, has spent much of his life fighting alongside other activists to open Insite, Canada’s first legal medically supervised space that provides sterile equipment to people who inject drugs – and keep it open.

Since its doors opened in 2003, the small, bright space has logged more than 3m visits. A staff of 10 – including three nurses – are on site as people bring in their drugs and inject them in one of the 13 mirrored booths before moving to a lounge area. Others drop by to access healthcare, counselling or inquire about detox programs.

The relaxed atmosphere belies the critical role it plays in saving lives: by 2015, staff here had intervened in 4,922 overdoses, all without one death. The dozens of studies carried out on the site have yielded further insights: Insite does not lead to increased drug use or crime but instead offers a unique means of building relationships while saving lives, preventing the transmission of HIV and hepatitis C and spurring more people into detox programs.

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Fourteen years after Insite opened its doors, the idea is now catching on. The federal government last year approved a second safe injection site in Vancouver and in recent weeks has given the green light to services in Montreal, Toronto and Surrey.

Interest has also been percolating south of the border; groups in Seattle, San Francisco and New York City, among others, are currently exploring the creation of similar facilities.

Much of the current attention stems from the opioid crisis that has claimed thousands of lives on both sides of the 49th parallel. The roots of Insite, however, lie in another crisis: in the late 1990s, Downtown Eastside was home to HIV rates that one researcher described as the highest outside of sub-Saharan Africa. “It was horrendous,” said Wilson. “If you walked down Hastings Street, people were literally dying in the alleys.”

Wilson and other activists pointed to western Europe, where supervised injections sites had been successfully launched decades earlier. But in North America, the debate was coloured by ideology and the war on drugs, and the battle was drawn out over years.

When Insite finally opened, Wilson was its first client. “I started using drugs when I was 12 years old. Heroin was always a constant in my life, cocaine I used a bit here and there.” His mother warned that if opening the first site had seemed tough, the battle for the second site would be even more difficult.

Her words proved prescient. The 2006 federal election ushered in the Conservatives and their tough-on-crime agenda, setting the stage for a court battle aimed at shutting down InSite.

What followed was a David and Goliath battle, with Wilson and another Insite user challenging the government in Canada’s highest court. “When we won, I thought, ‘Well now we’ve got this constitutionally enshrined,’” said Wilson, who is now stabilised on methadone and rarely uses drugs. “Then the bastards tried to regulate us out of business.”

Through new legislation, the government made it more onerous to open safe injection sites, with demands that included multiple letters of support, reports detailing statistics on crime and HIV rates and background checks for staff members.

Meanwhile the opioid crisis tightened its grip across Canada. Overdose deaths soared as fentanyl – a drug that is 50 times stronger than heroin – and other opioid analogs began to taint the supply of illicit drugs.

The rocketing number of deaths led the provincial government of British Columbia to declare a public health emergency in April 2016. Still the number of deaths continued to climb, claiming 935 lives last year. The trend shows little sign of abating: in the first four months of this year, 488 people in the province have died of overdoses.

Across Canada, at least 2,300 people died of overdoses last year, Jane Philpott, the country’s health minister, said last month. “The death toll is worse than any other infectious epidemic in Canada – including the peak of Aids deaths – since the Spanish flu that took the lives of 50,000 people a century ago.”

Since taking power in 2015, Philpott’s government has expedited approvals of safe injection sites, but has faced criticism for not doing more to address the soaring number of deaths.

In British Columbia, the result has been more than a dozen barebones overdose prevention sites, offering a place for people to consume drugs and be monitored for signs of an overdose.

The four tables at one such site, the Maple Overdose Prevention Site, have been constantly occupied since it opened six months ago. Three to four people staff the site at a time, handling some 200 visits a day. So far they’ve caught more than 400 overdoses without one death. “There are some, you get to them and they’re as blue as a blueberry,” said staff member Sue Ouellette.

Ouellette turned her attention to a woman in her 20s, slumped in her chair after injecting heroin. After the woman said she had been given a painkiller while at the dentist earlier in the day, Ouellette checked her vital signs and injected her with naloxone, the fast-acting antidote for opioid overdoses.

“There isn’t anybody in all the months that I’ve worked here that hasn’t had some kind of history,” said Ouellette, 58. “They all have a broken heart, broken soul or broken bodies. So this is the best thing that I can do – I’m not a nurse, I’m not a doctor but I can help. I can’t stop people from doing drugs, but I can stop them from dying.”

The grassroots battle playing out on the streets of British Columbia is a sharp contrast to other public health crisis: the Sars epidemic in the early 2000s claimed 44 lives in Canada but prompted the creation of a public health-focused government agency, said Jordan Westfall of the Canadian Association of People Who Use Drugs.

“I think if it was any other group of people dying like this, we would have handled it a long time ago,” he said.

For Westfall, supervised injection clinics are a “half measure”. An even better answer, he said, sits blocks away from Insite at the Providence Crosstown Clinic, the first space in North America to provide addicts with medical-grade heroin.

“You actually give people the drug so you interrupt that hustle on the streets,” he said, freeing up time for people to hold down jobs, go back to school or care for their family. “Whereas Insite – which is great too – doesn’t really do that. You still have to obtain your drugs on the street, which comes with a host of issues. When you’re living like that, it’s hard to imagine how much trauma you go through day to day without any time to process it because you have to keep going and going.”

The Crosstown clinic – based on similar models that have been operating in Europe for decades – opened in 2004 as part of a trial. Today 95 people visit Crosstown regularly for heroin-assisted treatment, after having tried an average of 11 other methods to quit drugs, said Scott MacDonald, the lead physician at the clinic. “Our goal is to get people into care and retain them in care so they don’t have to use illicit opioids.”

Clients visit the clinic two or three times a day. Each time they’re given heroin and sterile equipment and are supervised while they inject. Some continue to use heroin for a long time, but the clinic has so far seen at least 10% of its clients pull back on their drug use.

“This is not about providing free drugs,” said MacDonald. “It’s about providing better care and reducing the burden on society.” It costs the provincial government about C$27,000 a year to fund a Crosstown client, as opposed to an estimated C$48,000 spent a year on health, policing and judicial costs for those who are dependent on illicit opioids.

The opioid crisis has brought renewed attention to the model, sparking interest across Canada and in the US in recent months, said MacDonald. “My hope is that eventually this would be normalised, available to everybody that needs it and just part of routine care. But that’s going to take some time,” he added. “And some of that’s discrimination, some of that’s fear. But with time, with the overwhelming quality and depth of evidence, it’s going to happen.”